SEMIOLOGY IN UROLOGY

HOW DOES THE PATIENT

COME TO SEE THE DOC?

• Anamnesis: very important

• Modern medicine: nobody has time

• Personal records (medical history, lab

values etc.)

• All signs and symptoms

 PAIN IN UROLOGY
LUMBAR PAIN

• Localization

• Irradiation

• Intensity

• Associated digestive symptoms,

• Associated urinary symptoms – micro-hematuria
 PAIN IN UROLOGY
LUMBAR PAIN – differential diagnosis
• Biliary colic
• Ulcer, pancreatitis
• Acute appendicitis
• Salpingitis, depherentitis
• Pleural and pulmonary diseases
• Very intense pain, in hypoxia /anoxia /
obstruction or torsion of the intestine
 PAIN IN UROLOGY
LUMBAR PAIN – differential diagnosis
• One side pain – more important
• Elderly male patients receiving treatment for a
rheumatic disease  Metastasis in prostate
cancer
• Pain in urinary lithiasis
– Urinary changes
– Echo: the patient has to undress  Zoster Zone

• Renal colic with fever

 PAIN IN UROLOGY
HYPOGASTRIC PAIN
• Young woman, polakiuria, “muddy” urine
 cystitis
• Woman, polakiuria, without pyuria,
symptoms resisting at antibiotics
 candidsis / Hyperreactive bladder
/vaginal infection / endocrine disorders /
lithiasis
 PAIN IN UROLOGY
PERINEUM PAIN
• Young man  prostatitis
• Woman  gynecological problems

PAIN IN SCROTUM
• Young man, very intense pain  testicular torsion
– 6 hours!!!
• Testicular hydatide torsion
• Acute Orhchyepididimitis
• Viral orchytis
 HEMATURIA
• Is it hematuria ?
– Drugs that color the urin: piramidon,
nitrofurantoin
– cumarol
– Bilirubinuria – jaundice
– Hemoglobinuria

• Hematuria localization
– Cystoscopy (in anesthesis)
 HEMATURIA
• Etiology:
– Neoplastic diseases
– Lithiasis – hematuria with pain
– tuberculosis – persistent micro-hematuria

• Bladder tumors :
– Painless whimsical hematuria, age > 40 years
– Investigations: echo, urography, CT, MRI
 PYURIA: “muddy” urine at
evacuation
• Renal diseases
– Lithiasis
– Tuberculosis
• Bladder diseases
– Infections, bladder lithiasis
– Prostatic disease
• Urinalysis
• Treatment: acidifying the urine
 URINATION (MICTION)
CHANGES

• Polakiuria: frequent and low

quantitative urination

• Dysuria: difficult miction

• Thin urinary jet

 DYSURIA: difficult miction
• Children: subvesical diseases
– Vesical cervix sclerosis
– Posterior urethral Valves
– Phimosis
– Urethral meatus stenosis
• Pathophysiology:
– After miction residue dilation + incontinence 
hydronephrosis  acute urine retention
 DYSURIA IN MEN
• Young men:
– Acute prostatitis: fever
– Urethral stenosis
• Elderly men:
– Prostate adenoma
– Prostate cancer
– Vesical cervix sclerosis
– Urethral stenosis
– Perianal infections
 DYSURIA IN WOMEN
• Leziuni organice
– Uterus cervix neoplasm – cytology
– Urethra neoplasm
– Vesical cervix sclerosis
– Central nervous system disorders – multiple
sclerosis
– Diabetes mellitus
– After radical surgery
 DIURESIS CHANGES
• Normal urinary volume: 800-2000 ml/24h
• Diuresis monitoring: 24h  5 zile
• Polyuria (>3 l/day): diabetes insipidus, diabetes
mellitus, chronic renal failure – compensatory
mechanism, increased water intake
• Anuria: no urine in the bladder
– Prerenal causes: prolonged hypotension, shock
– Renal causes: drugs, infections
– Postrenal causes: urinary tract obstruction
 BLADDER FUCTIONS

• Urine reservoir

• Urine output
– Bladder contraction
– Sphincter relaxation
ANATOMIC DIFFERENCES
WOMAN / MAN
 URINARY INCONTINENCE
CAUSES:
• C.N.S. disorders
– Tabes, multiple sclerosis, Alzheimer’s,
cerebral hemorrhage, Parkinson’s
– Vertebral traumas with medulla interest
– Radical surgery

• Enuresis in children
 CAUSES

• Congenital Causes:
– Epispadias gr. III
– Bladder extrophy
– Ectopic urether opening

• Traumas:
– Fistula (vesical-vaginal, urether-vaginal, complex)
- Incontinence after prostatectomy
EMBRIOLOGIE
 FUNCTIONAL INCONTINENCE

• Very frequent

• Causes:
– Bladder
• Hyperactive
• hypocontractile
– Vesical cervix
• Obstruction
• Incompetence
FUNCTIONAL INCONTINENCE
• Hyperactive bladder
– Idiopathic
– Infections
– Bladder tumors
– Bladder lithiasis

• Hypocontractile bladder
– Tumor compressions on the spine
– Diabetes
– Connective tissue replacement (chronic obstructions)
FUNCTIONAL INCONTINENCE
• Sphincter incompetence
– Effort incontinence in women
– Men: after TUR / surgery
– Diabetes mellitus

• Vesical cervix obstruction

– Dysuria – in children
– Prostate adenoma, urethral stenosis, vesical cervix
sclerosis – in men
– Genital cancer, urethra stenosis, perianal phlegmon –
in women
 ACUTE RENAL FAILURE

• Rapid decline in glomerular filtration rate

• Retention of nitrogenous waste products
• Perturbation of extracellular fluid volume and electrolyte
and acid-base homeostasis
• Oliguria: frequent, but not invariable clinical feature
• Usually asymptomatic
• Most ARF is reversible
CLASSIFICATION AND MAJOR CAUSES
OF ARF
 PRERENAL ARF
I. Hypovolemia
A. Hemorrhage, burns, dehydration
B. Gastrointestinal fluid loss (vomiting, diarrhea etc)
C. Renal fluid loss (diuretics, diabetes mellitus)
D. Sequestration in extravascular space (pancreatitis, peritonitis, burns
etc)
II. Low cardiac output
A. Diseases of myocardium, valves and pericardium; arrhythmias,
tamponade
B. Other: pulmonary HTN, massive pulm. embolus, positive pressure
mechanical ventilation
III. Altered renal systemic vascular ratio
A. Systemic vasodilatation: anti-HTN drugs, anesthesia
B. Renal vasoconstriction: ↑ Ca, epinephrine, amphotericin B
C. Cirrhoses with ascites
IV. Renal hypoperfusion
V. Hyperviscosity syndrome: multiple myeloma, poycythemia
CLINICAL ASSESSMENT

• Thirst
• Orthostatic dizziness
• Orthostatic hypotension, tachycardia
• Decreased skin turgor
• Dry mucous membranes
LABORATORY FINDINGS

• Creatinine rises rapidly (within 24 to 48 hours)

• Peak creatinine levels: after 3-5 days, with return to baseline
after 5-7 days (in ischemic ARF and atheroembolization the
peak is later – 7-10 days)
• Hyperkalemia, hyperphosphatemia, hypocalcemia, ↑ uric
acid, ↑ CK-MM ► rhabdomyolisis
• Hyperuricemia, hyperkalemia, hyperphosphatemia,
increased circulating levels of intracellular enzymes – LDH –
► acute urate nephropathy and tumor lysis syndrome
following cancer chemotherapy.
 INTRINSIC RENAL ARF
I. Renovascular obstruction (bilateral or unilateral)
A. Renal artery obstruction
B. Renal vein obstruction: thrombosis, compression
II. Disease of glomeruli or renal microvasculature
A. Glomerulonephritis, vasculitis
B. Hemolytic uremic syndrome, thrombotic thrombocytopenic purpura,
disseminated intravascular coagulation, toxemia of pregnancy, accelerated
HTN, radiation nephritis, systemic lupus erythematosus, scleroderma
III. Acute tubular necrosis
A. Ischemia: as for prerenal ARF, obstetric complications
B. Toxins (exogenous, endogenous)
IV. Interstitial nephritis
A. Allergic (drugs)
B. Infection
C. Infiltration (lymphoma, leukemia, sarcoidosis)
D. Idiopathic
V. Intratubular deposition and obstruction
VI. Renal allograft rejection
CLINICAL ASSESSMENT

• Ischemia: following severe renal hypoperfusion and ARF

persistence despite normalization of systemic
hemodynamics
• Flank pain: occlusion of renal a./v., other parenchymal
diseases
• Subcutaneous nodules, livedo reticularis, digital ischemia
– atheroembolizations
• Edema, HTN, “active urine sediment” (nephritic sdr.) –
acute GN or vasculitis
• Fever, arthralgias, pruritic erythematous rash after a new
drug adm. – allergic interstitial nephritis
 POSTRENAL ARF

I. Ureteric
I. Calculi, blood clot, cancer, external compressions
(retroperitoneal fibrosis)
II. Bladder neck
I. Neurogenic bladder, prostatic hypertrophy, calculi, cancer,
blood clot
III. Urethra
I. Stricture, congenital valve, phimosis
CLINICAL ASSESSMENT

• Suprapubic and flank pain (bladder, renal collecting

system and capsule distension)
• Colicky flank pain radiating to the groin – acute ureteric
obstruction
• History of nocturia, frequency, and hesitancy and
enlargement or induration of the prostate – prostatic
disease
• Anticholinergic drugs, autonomic dysfunction –
neurogenic bladder
TREATMENT

• PRERENAL ARF
– Correct hypovolemia (packed red cells, isotonic saline)
– Correct dyselectrolytemias and acid-base status
– Correct / eliminate the cause
• INTRINSIC RENAL ARF
– Measures to attenuate the injury or hasten recovery in ischemic
and nephrotoxic ARF (low-dose dopamine, loop-blocking diuretics,
Ca ch. Blockers, alpha-blockers, antioxidants)
– GN, vasculitis: glucocorticoids, alkylating agents and/or
plasmapheresis
– HTN, scleroderma: ACE inhibitors
DIALYSIS

• Absolute indications:
– Symptoms or signs of uremic
sydrome
– Refractory hypervolemia,
hyperkalemia, acidosis
– Blood urea levels > 100 mg/dl
(not firm indication)